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First off, triple-nucleoside combos of tenofovir , abacavir and another nuke (3TC, ddI etc) have a high rate of failure. Do not use except for maintenance if you already have a viral load &lt;50, and not as a switch from another combo (says the UK guidelines). Several studies, eg ESS30009, have demonstrated this, and the European Medicines Evaluation Agency, for one, issued a treatment alert (reported in many places including here).

""TDF/ABC/LPV [Kaletra] regimens in HAART experienced patients had a surprisingly high success rate of 84%. Furthermore, all failures had low level viremia (VL&lt; 750). Prior exposure to PIs and mutations did not effect outcome. To what degree TDF and ABC are contributing to LPV's effects in the success of this regimen is unknown. A prospective study needs to be done as TDF/ABC/LPV remains a highly used regimen and is now recommended as a salvage regimen in the revised WHO 2003 guidelines.""

"The Spanish RECOVER Trial was a prospective evaluation of virologically suppressed patients who switched from any NRTI to tenofovir. Of 1350 subjects enrolled in this study, 101 were switched to a regimen including abacavir and tenofovir; 51 of these received the 2 drugs as parts of a triple-NRTI regimen, 30 received abacavir/tenofovir with an NNRTI, and 20 with a protease inhibitor (PI). Eighty-seven percent of patients were on their third or greater antiretroviral regimen. After 24 months, only 3 patients receiving NNRTI- or PI-based regimens had virologic failure, all of which was attributed to noncompliance. By contrast, 8 of 51 (16%) patients receiving triple-NRTI regimens had virologic failure."

And:

"Ward reported a retrospective review of 138 patients who received abacavir/tenofovir in a triple-NRTI regimen in a single practice. As in RECOVER, the majority of these patients were already virologically suppressed and switched to this combination for reasons of toxicity; however, patients who received this combination as initial therapy or as a new regimen after failure were also included. Seventy-four percent of patients had previous NRTI resistance. After a median of 26 months of follow-up, only 8% of patients experienced virologic failure; another 9% had persistent low-grade positive viral loads. "

Set agains this are other studies showing increased rate of K65R mutation on people using tenofovir+abacavir with NNRTIs like Sustiva, less so with boosted protease inhibitors, though this is complicated to analyse because you need to differentiate the people who used tenofovir as a first-line drug (very very low chance of K65R), people who switch with viral load &lt;50, people with treatment experience (do worse) plus the adherence factors (do worse).

My doc will prescribe tenofovir+abacavir with boosted PIs but not with NNRTIs except as part of salvage.

"...the combination of TFV and ABC was found to be additive with respect to inhibition of HIV replication. Addition of 3TC to the combination did not result in synergistic or antagonistic effects. CONCLUSIONS: The poor efficacy of the triple NRTI regimen of TDF, ABC and 3TC is probably not due to a metabolic drug interaction resulting in antagonism of antiviral activity."

My view: the picture is not simple, except for a big DO NOT USE for triple nuke combos including tenofovir+abacavir . The results are good in many studies for tenofovir+abacavir with boosted PIS and NNRTIs.

I used Abacavir/Tenofovir/3TC for about 12 months and the treatment failed. I missed only like 3-4 doses of abacavir in the 12 month period. I was given the combo because I couldn't tolerate efavirenz and I had liver issues so nevirapine was out.

I didn't learn until later (and from this site I think) that ABC/TFN/3TC is a deprocated combo because of the awful failure rate. I'm fairly lucky though. I've got high level resistance to 3TC (no biggy) and I'm resistant to Tenofovir too. I also ended up resistant to AZT, something which I've never taken.

I was always on Viramune, epivir, ziagen, since the beginning. Actually Zerit was used a month or so, prior to switching to Ziagen. When Epzicom, became available, I switched to that, to make dosing easier. it was basically the first regimen I was started on, back in October of 2003.

Viread was added to the mix, it was either August or September 1st, Of 04.Was having trouble getting to <50 viral load. But have succeeded, at keeping <50 since the Viread was added. (except for one blip of 166) I am still waiting on a viral load, should be in sometime this week. So, we'll see what happens.

I had some muscle ache and weakness, after the Viread was added. This lasted less then 4 weeks. The main side effect I deal with is PN. And that occurred, well before Viread was introduced. Also dealing with larger then normal gut area ! But, otherwise, things are not that bad. Day by day...

as this is now on page two I am hoping someone will still read it and be able to give me some advice.

As I am staring lipo in the eyes right now and it is not too bad yet, I've asked my doctor what the options were if I switched from my current epivir + zerit duo. He suggests Ziagen + Kaletra + Viread.

I am very new to all the jargon and have a hard time understanding all Newt writes here. So please give me the lowdown on this combination and I promess I will try to learn "Newtspeak" soon.

The combination suggested by your doc is not standard. Ziagen + Viread is not a recommended first-line nuke pair. But even though it's not standard, you will probably get a good response on Kaletra + Viread + Ziagen.

As I am staring lipo in the eyes right now and it is not too bad yet, I've asked my doctor what the options were if I switched from my current epivir + zerit duo. He suggests Ziagen + Kaletra + Viread.

Does the doctor suspect both 3TC and Zerit to be involved in the lipo or is he just going for a clean break? I'm just wondering why he didn't continue the 3TC (or FTC via Truvada), and simply dropped the Zerit.

so if I am not too thick, the combivir is equivalent to my present treatment of zerit + epivir right? I am not sure why my doc would not keep the epivir and just drop the zerit and it is a question I will ask him.

And Newt, thank you for the explanation and the french link. I just hate accronyms and I have a technical job just full of them...Could you tell me why it is that Ziagen + Viread is not recommended?

Zerit is d4T. Combivir is AZT+3TC. So Zerit + Epivir (3TC) is different from Combivir.

d4T is most nasty in terms of lipo, AZT less so. Unless you have resistance that means you must use d4T or AZT, there's no reason to use these drugs. Ziagen or Viread are very good and don't cause lipo like AZT and d4T. Plus they's stronger.

Ziagen + Viread got a bad name from being used in triple-nuke combinations because the results weren't good. It is therefore not recommended for use with one other nuke. Recent studies on these two drugs + a PI show good results.

All of this is complicated because each anti-retroviral (ARV) drug has three names: (1) The brand name under which it is sold by the pharmaceutical company -- Viread, Ziagen etc; (2) a generic name for the chemical in the drug -- tenofovir, abacavir; and (3) an abbreviation of the generic name consisting of three letters -- TDF, ABC.

So your doctor is recommending two nukes (NRTIs), the "backbone" of triple-drug treatments, which is standard. Less standard is his choice of the two nukes. The widely-used -- and widely-studied -- double nuke combos are listed by newt. Here are some facts to consider:

Assuming that you want to rule Combivir (AZT/3TC) out since it contains AZT (a lipo suspect), then all of the combos listed by newt, as well as the one suggested by your doctor, have twic-daily dosing. For once-daily dosing, your option is Truvada -- which is Viread + Emtriva (FTC).

In addition to one of these two-nuke combos, you'd take a non-nuke (NNRTI) or a protease inhibitor (PI). (Many PIs are boosed with norvir; this simply means that a small dose of norvir is added to the main PI to make it more effective.) Kaletra can be taken once-daily if you're treatment-naive, but since you've already taken ARVs for a while, it has to be taken twice-daily. You can also ask your doctor about boosted Reyataz (atazanavir with norvir added if needed). That's once-daily too. Finally, there's the NNRTI option, almost certainly Sustiva (efavirenz) -- that's once-daily too. In fact, a once-daily pill combining Sustiva and Truvada was recently approved in the United States -- a once-daily dosage of three powerful ARVs, the simplest and most convenient drug regimen as of now.

OK, hope this wasn't too much. What I'm trying to say is: you have plenty of options. If simplicity of dosing is important to you then you can take Truvada + Sustiva or Truvada + Reyataz. If you want to go with the tried and tested, you can go with Kixeva or Truvada (the two nukes) + Sustiva or Kaletra or Reyataz. (Plus some others I'm not going to list.) You would need to study the side-effect profile of the drugs. Finally, echoing newt again, just because the regimen suggested by your doctor (the two nukes) isn't standard, it doesn't mean that it won't be effective.

Her finely-touched spirit had still its fine issues, though they were not widely visible. Her full nature, like that river of which Cyrus broke the strength, spent itself in channels which had no great name on the earth. But the effect of her being on those around her was incalculably diffusive: for the growing good of the world is partly dependent on unhistoric acts; and that things are not so ill with you and me as they might have been, is half owing to the number who lived faithfully a hidden life, and rest in unvisited tombs.

your posts help a lot! as a side effect I already feel a bit less stupid

I am pretty good at organizing/managing stuff so to have to take some drugs once and others twice is ok. I have asked my doc about the reason for dropping epivir and am waiting for his answer (we use mail a lot as he is 3 hours down the road... but it's a nice road )

I came out of the doctors office this afternoon with some very mixed emotions. I felt a little upset and disappointed. My initial appointment date was August 15th, but I managed to have it moved up to today.

My doctor will not budge on the issue of the regimen that I on. He points out that the early viralogic failure that may be associated with Viread, Ziagen and epivir, was when there were NO other drugs, either a PI or a Non-nuke involved with that combination.

He is insisting that my blood test results are fine, ( of course < 50 would be absolutely ideal, and that is what we keep striving for) Once again we spoke briefly about viral load "blips" and treatment failure.

He insisted that if the viral load continues to rise, without falling back to undetectable, that indeed, a change in medications would be considered. But not yet in my case !! He reaffirmed, that my blood test results ( chemical screen ) and other other tests are still very good. And he has no problem with those results. I asked if he felt I should be seeing him more often, then once every three months, he said no.

I had explained to the doctor, that I had not been feeling the greatest lately. The neuropathy is kicking in full time. My skin feels as though I have a constant sunburn, this pressure in my neck and shoulder area, the weakness and minor muscle cramping that I am experiencing, mostly in my upper legs and calf muscle area, periodic sweats. and of course this very mild pressure just below the abdomen. Sometimes being just a very dull ache ( but never persistant.)

Everything else, Appetite, bowel movements weight is normal, with no problems in that area.

He decided to have me temporarily stop the ZOCOR. And see if there is any improvement in a week or so, in the area just below the abdomen.

He also gave me "AMITRITTYLINE." Gave me about a month supply of this drug. I thought this was a substitute for Zocor,, so I was quite surprised, when I got back from the doctor and punch this up on the computer, to find that it's an anti-depressant.

Anybody else familiar with "AMITRITYLINE "?... So now I guess I am depressed.... I thought (my partner thought , that I have been doing great! I still am not sure why he wanted me to try this drug.

There was more vials of blood taken today ( then usual) 8 total ! Those results would come back in 7 to 10 days. The doctor will then look at those results, and get back in touch with me.

When I left the doctors office today, I had to pull over to the side of the road. For some reason I was angry and upset. I didn't want to pull the steering wheel off the column while driving

Does anybody remember the episode of the "golden girls" when Dorothy was sick, and the doctors brushed it off.told her nothing was wrong. That it was "in her head" When in fact she was later diagnosed with Chronic fatigue syndrome. For some reason, that episode was on my mind today when I left the doctors office. I felt as though I was being a pest/nuisance or taking his time today, because I was asking questions.

Sorry to hear about the outcome of the visit. The one good thing that came out of it was you were able to get the blood test done earlier. So I suppose it is reasonable to wait and see what this one shows before planning your next move.

Quote

He points out that the early viralogic failure that may be associated with Viread, Ziagen and epivir, was when there were NO other drugs, either a PI or a Non-nuke involved with that combination.

That is certainly true; that's why it's very difficult to come up with a "right decision" in your particular situation, especially when considering that you are tolerating this combo so well.

Regarding the amitriptyline, it is in fact an older antidepressant but it is also used in peripheral neuropathy. Temporarily stopping the Zocor is also a reasonable move just to make sure this is not contributing to the pain problem (which it can sometimes do).

It sounds like your doctor is doing all the right things and is being reasonable as it concerns your treatment, EXCEPT for the fact that he isn't communicating with you. You shouldn't be leaving his office in such a state that you need to pull over to calm down. It's not enough to treat people, doctors also need to effectively communicate exactly what they are doing and more importantly WHY. Case in point, prescribing the new drug but not telling you why...forcing you to go look it up, only to cause more anxities because it's for depression. He should have told you exactly why he was prescribing this med.

Virologically, immunologically your doc thinks you's doing alright. But you feel like crap. Not a good result and wrong that you leave his clinic not reassured.

Amitriptyline is used extensively, often with good results to treat diabetic and post-herpetic neuropathy, but me, personally, I thought it was like prescription acid. It is metabolised extensively by the liver. While this may not be a problem for most people, and may not be for you, it should be used with caution in people with impaired liver function (as per the drug's prescribing info...I am guessing your doc is smart and wouldn;t give out this drug if your LFT was abnormal).

Thanks for responding ! I am doing a lot better today then i was doing yesterday. Yes, there certainly needs to be more communication, between the doctor and myself. It seems as though, when I really get started , he seems to be in a rush to exit the room (forces me to sniff my armpits, and see if I got some type of odor problem !!

All my liver function tests are ok,( unless those results have changes since my July tests) so there shouldn't be a problem starting the amitriptyline. I am not to start this until Monday, and I have discontinued the Zocor. It is to be taken before I go to sleep. which by the way is at noon, because of the shift I work. So I will have to see how this effects me, when I go into work at 11:00pm.

So, I will just wait for these last blood test results, and go from there.

Two things I've noticed about using amitriptyline and other drugs from the tri-cyclic anti depressant family:

1. They are VERY sedating. Especially in the early phases of use;2. There is a tendency for some people to develop urinary retention -- ie it can be hard (and in some very rare cases impossible) to pee.

Outside of that, they can be very effective for the various purposes to which they are employed.

Thanks for that. Hopefully I won't be too sedated to go into work, 11 hours later. I am not even sure what the dosage is on these pills, or if it varies. I need a magnifying glass to see whats on the pill.

Yes, there certainly needs to be more communication, between the doctor and myself. It seems as though, when I really get started , he seems to be in a rush to exit the room

Don't they all....Maybe a pre-written list would help, handed to him as soon as he walks through the door. This will force him to check off each item with you before he leaves the room. I used it a couple of times, (when I was first diagnosed), and it worked pretty well.

Good luck Ray and let us know how things go when you get yours test results back.